Internationally, there has been increased emphasis on improving the quality of care in continuing care settings (that is, home care, supportive living, and facility-based long-term care) [1–3]. There has also been an emphasis on unregulated care providers’ role in delivering high quality care in long-term care (LTC) settings [4, 5]. Audit with feedback is a quality improvement approach that is moderately effective for improving regulated professional practice in several health care settings [6, 7]. However, little is known about how unregulated care providers understand and perceive feedback reports in LTC settings. The purpose of this paper is to explore the perception of audit with feedback reports by unregulated providers in LTC settings.
The long-term care (LTC) setting
Residents within facility-based LTC settings in Canada are vulnerable people who need substantial personal care and on-site, 24-hour nursing care [1, 8, 9]. “Personal care” refers to help with daily living activities (e.g. bathing and eating) and other therapeutic interventions (e.g. medication reminders), as well as managing behaviour related to diseases (e.g. dementia-induced wandering) .
A current trend in caring for older Canadians experiencing functional or cognitive decline (or both) is to provide supportive care within a person’s home or in an assisted living setting for as long as possible . This “aging in place” approach (8), along with supporting individuals and families for as long as possible within community settings, is emphasized in numerous Canadian jurisdictions [1, 9], including Alberta . However, many individuals or their families still choose LTC settings, often when community support can no longer manage the patient’s substantial health needs [8, 9]. In Alberta in 2008, 14,500 seniors or persons with disabilities (or 0.40% of the province’s population), lived in a LTC facility [10, 11].
In 2010, there were 2136 Canadian LTC facilities with 212,948 staffed beds. In Alberta in 2010, there were 199 LTC facilities with 18,738 staffed beds . While Canadian LTC residents often require less medical, nursing, or personal care compared to hospital patients , they tend to have higher levels of dependency and cognitive impairment than seniors living in the community . In Alberta specifically, LTC residents’ care needs were 35% higher in 2003 than in 1990. With 75% of these residents in the highest of three categories of need—specifically for functional care  —these data suggest an increase in care intensity over time.
Unregulated care providers
LTC in Canada is a provincial responsibility  and, as a result, characteristics of LTC environments vary from province to province . However, common across all Canadian LTC settings is the high proportion of unregulated care providers (that is, unlicensed staff who may also be referred to as care aides, nurses aides, or personal care workers in other jurisdictions across Canada and abroad) who deliver the majority of front-line, direct care to residents . In 2007, 72% of care providers in LTC in Alberta were unregulated caregivers; regulated professionals (like registered nurses (RNs)/registered psychiatric nurses (RPNs) and licensed practical nurses (LPNs)) comprised only 17% and 11%, respectively .
Unregulated caregivers give basic care, including personal and supportive care, under the supervision of a regulated professional (an RN/RPN or LPN) [3, 16, 17]. They also recognize and report resident symptoms that require a regulated health professional’s intervention . Hence, they have been described as the “backbone” of LTC [16, 18].
Educational preparation of unregulated providers varies widely, especially given a high proportion are educated immigrants who do not have professional licensure in Canada. In comparison with RNs and LPNs who have either a mandatory four-year baccalaureate degree or a 15-month to two-year diploma [8, 19], unregulated caregivers generally have lower levels of education. Many unregulated caregivers train on the job; some have obtained a personal care attendant certificate by attending a 12 to 40 week program delivered through a college or vocational school . Alberta, along with many other Canadian provinces, has no mandatory or standardized approach for educating unregulated care providers  and the Government of Alberta recognizes the need to certify its approximately 16,000 unregulated providers, as one approach to ensure provision of quality care . The province developed competency profiles  and, since 2008 has been considering whether all unregulated care providers will be required to obtain a recognized education certificate or complete a competency assessment.
Quality of care
The increasing complexity and intensity of care needs in LTC residents result in “challenges in meeting human resources and continuing staff education needs” , p. 22]. As well as increasing numbers of LTC residents, a wide range of challenging co-morbidities often influence their needs , yet it is unregulated care providers (with the lowest level of education and pay) who are most in contact with them [14, 16]. LTC thus relies on the least prepared individuals to provide the majority of care to a growing number of older adults with multifaceted health needs [8, 22, 23]. The high proportion of unregulated care providers may affect the quality of care in LTC settings, as they may be limited in their ability to respond appropriately to residents [14, 24].
Broader contextual factors may also impact the delivery of care within LTC settings. Unregulated care providers have little autonomy  and decision makers rarely consult them [16, 24]. Improving teamwork among the variety of care providers— especially between professional nurses and unregulated care providers—might improve quality of care [25–27]. A partnership approach between unregulated caregivers and management, rather than a hierarchical one, may improve unregulated providers’ quality of care . This approach would empower them, involving them in decision-making  and creating a culture in which they are treated with “respect, support, and caring” , p. 637]. Thus, including unregulated care providers in activities traditionally left to professionals, such as quality improvement interventions, could be an important way to improve the culture [5, 29, 30], improving the overall quality of care in LTC settings [31–33].
Audit with feedback interventions
One approach to improving quality of care is through audit and feedback. This is the auditing of current care practices or resident outcomes and provision of the resulting data as feedback to care providers, in an effort to influence their clinical practice [6, 7]. Audit with feedback has the potential to influence health care provider behaviour, because it shows providers how residents in their facility compare to residents in other similar settings in selected areas affected by the care that they deliver . The ultimate goal of an audit with feedback intervention is improving the quality of care [6, 7].
Audit with feedback has modest effects on professional practice, with effects tending to be greater in settings with little prior exposure to this type of intervention [6, 7, 25]. Minimal evidence is available on the effectiveness of audit with feedback in LTC settings and, in particular, the effects when targeting unregulated care providers. In one randomized clinical trial, the researchers targeted the professionals (the LTC administrator and director) with feedback, but not the unregulated care providers. Further, the authors do not report to what extent the professionals passed the information on to other providers in their facility . We currently do not know how unregulated providers, when directly targeted, might perceive and respond to feedback report information within LTC contexts; this study’s results will begin to fill this knowledge gap by identifying how unregulated care providers perceived the information included in the report. Although self-reported intent-to-change behavior is not the focus of this study, unregulated providers’ perceptions of the utility of the feedback report information may be an important initial factor that influences whether a plan to change practice is made. Intent-to-change behavior will be reported in a separate publication.
The need for formalized audit with feedback processes
In Alberta and several other jurisdictions across Canada and internationally, standardized data are readily accessible for audit with feedback in LTC settings. The data come from the Resident Assessment Instrument-Minimum Data Set version 2.0 (RAI 2.0). The RAI 2.0 is a standardized assessment tool, mandated by Alberta Health and Wellness in LTC settings across Alberta. Developed by the interRAI consortium, it is used within Canada and internationally to assess and document a wide variety of LTC resident characteristics, including physical, mental, and functional status [36, 37]. When aggregated to the unit or facility level, RAI 2.0 data also permit estimation of quality indicators. These measure the incidence and prevalence of resident health problems or outcomes that the quality of care within a unit or facility may influence.
Alberta LTC settings have not instituted formalized audit with feedback processes to date. The availability of these standardized data and the lack of a current audit and feedback approach provide an opportunity to test an audit with feedback intervention for care providers and managerial employees in LTC, and to obtain evidence about unregulated caregivers’ perceptions of the feedback report information . The aim of this paper is to describe unregulated caregivers’ perceptions of usefulness of a feedback report within LTC settings in a large urban centre in Alberta, Canada. Specifically, we were interested in understanding whether the reports provide information that unregulated care providers perceive could be useful to provide better quality care to residents, and to what extent other variables were associated with the perception of feedback report utility.